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Cedeno-Veloz BA, Erviti Lopez J, Gutiérrez-Valencia M, Leache Alegría L, Saiz LC, Rodríguez García AM, Sánchez Latorre M, Ramírez Vélez R, Izquierdo M, Martínez-Velilla N. Efficacy of Antiresorptive Treatment in Osteoporotic Older Adults: A Systematic Review and Meta-Analysis of Randomized Clinical Trials. J Nutr Health Aging 2022; 26:778-785. [PMID: 35934822 DOI: 10.1007/s12603-022-1825-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVES To investigate concerns surrounding the benefits of antiresorptive drugs in older adults, a systematic review was carried out to evaluate the efficacy of these treatments in the prevention of osteoporotic hip fractures in older adults. DESIGN a systematic review and meta-analysis of randomized clinical trials. SETTING AND PARTICIPANTS older adults ≥65 years with osteoporosis, with or without a previous fragility fracture. Studies with cancer-related and corticosteroid-induced osteoporosis, participants <65 years and no reported hip fracture were not included. METHODS MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, ISI Web of Science and Scopus databases were searched. The primary outcome was hip fracture, and subgroup analysis (≥75 years, with different drug types and secondary prevention) and sensitivity analysis was carried out using a GRADE evaluation. Secondary outcomes were any type of fractures, vertebral fracture, bone markers and adverse events. The risk of bias was assessment with the Cochrane risk of bias tool. RESULTS A total of 12 randomised controlled trials (RCTs) qualified for this meta-analysis, with 36,196 participants. Antiresorptive drugs have a statistically significant effect on the prevention of hip fracture (RR=0.70; 95%CI 0.60 to 0.81), but with a moderate GRADE quality of evidence and a high number needed to treat (NNT) of 186. For other outcomes, there is a statistically significant effect, but with a low to moderate quality of evidence. Antiresorptives showed no reduction in the risk of hip fracture in people ≥75 years. The results for different drug types, secondary prevention and sensitivity analysis are similar to the main analyses and have the same concerns. CONCLUSIONS Antiresorptive drugs have a statistically significant effect on preventing hip fracture but with a moderate quality (unclear/high risk of bias) and high NNT (186). This small benefit disappears in those ≥75 years, but increases in secondary prevention. More RCTs in very old osteoporotic adults are needed.
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Affiliation(s)
- B A Cedeno-Veloz
- Bernardo Abel Cedeño Veloz, MD, Geriatric Department (Hospital Universitario de Navarra), Irunlarrea Street 4, 31008 Pamplona, Navarra, Spain, E-mail:
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Fouad-Elhady EA, Aglan HA, Hassan RE, Ahmed HH, Sabry GM. Modulation of bone turnover aberration: A target for management of primary osteoporosis in experimental rat model. Heliyon 2020; 6:e03341. [PMID: 32072048 PMCID: PMC7011045 DOI: 10.1016/j.heliyon.2020.e03341] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Revised: 01/14/2020] [Accepted: 01/29/2020] [Indexed: 12/12/2022] Open
Abstract
Osteoporosis is a skeletal degenerative disease characterised by abnormal bone turnover with scant bone formation and overabundant bone resorption. The present approach was intended to address the potency of nanohydroxyapatite (nHA), chitosan/hydroxyapatite nanocomposites (nCh/HA) and silver/hydroxyapatite nanoparticles (nAg/HA) to modulate bone turnover deviation in primary osteoporosis induced in the experimental model. Characterisation techniques such as TEM, zeta-potential, FT-IR and XRD were used to assess the morphology, the physical as well as the chemical features of the prepared nanostructures. The in vivo experiment was conducted on forty-eight adult female rats, randomised into 6 groups (8 rats/group), (1) gonad-intact, (2) osteoporotic group, (3) osteoporotic + nHA, (4) osteoporotic + nCh/HA, (5) osteoporotic + nAg/HA and (6) osteoporotic + alendronate (ALN). After three months of treatment, serum sclerostin (SOST), bone alkaline phosphatase (BALP) and bone sialoprotein (BSP) levels were quantified using ELISA. Femur bone receptor activator of nuclear factor-kappa B (NF-κB) ligand (RANKL) and cathepsin K (CtsK) mRNA levels were evaluated by quantitative RT-PCR. Moreover, alizarin red S staining was applied to determine the mineralisation intensity of femur bone. Findings in the present study indicated that treatment with nHA, nCh/HA or nAg/HA leads to significant repression of serum SOST, BALP and BSP levels parallel to a significant down-regulation of RANKL and CtsK gene expression levels. On the other side, significant enhancement in the calcification intensity of femur bone has been noticed. The outcomes of this experimental setting ascertained the potentiality of nHA, nCh/HA and nAg/HA as promising nanomaterials in attenuating the excessive bone turnover in the primary osteoporotic rat model. The mechanisms behind the efficacy of the investigated nanostructures involved the obstacle of serum and tissue indices of bone resorption besides the strengthening of bone mineralisation.
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Affiliation(s)
- Enas A Fouad-Elhady
- Biochemistry Department, Faculty of Science, Ain Shams University, Cairo, Egypt
| | - Hadeer A Aglan
- Hormones Department, Medical Research Division, National Research Centre, Giza, Egypt.,Stem Cells Lab, Center of Excellence for Advanced Sciences, National Research Centre, Giza, Egypt
| | - Rasha E Hassan
- Biochemistry Department, Faculty of Science, Ain Shams University, Cairo, Egypt
| | - Hanaa H Ahmed
- Hormones Department, Medical Research Division, National Research Centre, Giza, Egypt.,Stem Cells Lab, Center of Excellence for Advanced Sciences, National Research Centre, Giza, Egypt
| | - Gilane M Sabry
- Biochemistry Department, Faculty of Science, Ain Shams University, Cairo, Egypt
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Yamada H, Ochi Y, Mori H, Nishikawa S, Hashimoto Y, Nakanishi Y, Tanaka M, Bruce M, Deacon S, Kawabata K. Effects of 16-month treatment with the cathepsin K inhibitor ONO-5334 on bone markers, mineral density, strength and histomorphometry in ovariectomized cynomolgus monkeys. Bone 2016; 86:43-52. [PMID: 26921823 DOI: 10.1016/j.bone.2016.02.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2015] [Revised: 02/21/2016] [Accepted: 02/22/2016] [Indexed: 12/29/2022]
Abstract
We examined the effects of ONO-5334, a cathepsin K inhibitor, on bone markers, BMD, strength and histomorphometry in ovariectomized (OVX) cynomolgus monkeys. ONO-5334 (1.2, 6 and 30mg/kg/day, p.o.), alendronate (0.05mg/kg/2weeks, i.v.), or vehicle was administered to OVX monkeys (all groups N=20) for 16months. A concurrent Sham group (N=20) was also treated with vehicle for 16months. OVX significantly increased bone resorption and formation markers and decreased BMD in lumbar vertebra, femoral neck, proximal tibia and distal radius. Alendronate suppressed these parameters to a level similar to that in the Sham-operated monkeys. ONO-5334 at doses 6 and 30mg/kg decreased bone resorption markers to a level roughly half of that in the Sham group, while keeping bone formation markers level above that in the Sham monkeys. Changes in DXA BMD confirmed that ONO-5334 at doses 6 and 30mg/kg increased BMD to a level greater than that in the Sham group in all examined sites. In the proximal tibia, in vivo pQCT analysis showed that ONO-5334 at doses 6 and 30mg/kg suppressed trabecular BMD loss to the sham level. However, ONO-5334 increased cortical BMD, cortical area and cortical thickness to a level greater than that in the Sham group, suggesting that ONO-5334 improves both cortical BMD and cortical geometry. Histomorphometric analysis revealed that ONO-5334 suppressed bone formation rate (BFR) at osteonal site in the midshaft femur but did not influence OVX-induced increase in BFR at either the periosteal or endocortical surfaces. Unlike alendronate, ONO-5334 increased osteoclasts surface (Oc.S/BS) and serum tartrate-resistant acid phosphatise 5b (TRAP5b) activity, highlighting the difference in the mode of action between these two drugs. Our results suggest that ONO-5334 has therapeutic potential not only in vertebral bones, but also in non-vertebral bones.
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Affiliation(s)
- Hiroyuki Yamada
- Discovery Research Laboratories, ONO Pharmaceutical Co., Ltd., 3-1-1 Sakurai, Shimamoto-cho, Mishima-gun, Osaka 618-8585, Japan.
| | - Yasuo Ochi
- Discovery Research Laboratories, ONO Pharmaceutical Co., Ltd., 3-1-1 Sakurai, Shimamoto-cho, Mishima-gun, Osaka 618-8585, Japan
| | - Hiroshi Mori
- Discovery Research Laboratories, ONO Pharmaceutical Co., Ltd., 3-1-1 Sakurai, Shimamoto-cho, Mishima-gun, Osaka 618-8585, Japan
| | - Satoshi Nishikawa
- Discovery Research Laboratories, ONO Pharmaceutical Co., Ltd., 3-1-1 Sakurai, Shimamoto-cho, Mishima-gun, Osaka 618-8585, Japan
| | - Yasuaki Hashimoto
- Discovery Research Laboratories, ONO Pharmaceutical Co., Ltd., 3-1-1 Sakurai, Shimamoto-cho, Mishima-gun, Osaka 618-8585, Japan
| | - Yasutomo Nakanishi
- Discovery Research Laboratories, ONO Pharmaceutical Co., Ltd., 3-1-1 Sakurai, Shimamoto-cho, Mishima-gun, Osaka 618-8585, Japan
| | - Makoto Tanaka
- Discovery Research Laboratories, ONO Pharmaceutical Co., Ltd., 3-1-1 Sakurai, Shimamoto-cho, Mishima-gun, Osaka 618-8585, Japan
| | - Mark Bruce
- Drug Development, ONO Pharma UK Ltd., MidCity Place, 71 High Holborn, London WC1V 6EA, UK
| | - Steve Deacon
- Drug Development, ONO Pharma UK Ltd., MidCity Place, 71 High Holborn, London WC1V 6EA, UK
| | - Kazuhito Kawabata
- Discovery Research Laboratories, ONO Pharmaceutical Co., Ltd., 3-1-1 Sakurai, Shimamoto-cho, Mishima-gun, Osaka 618-8585, Japan
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Abstract
UNLABELLED Current prevention strategies for low-trauma fractures amongst older persons depend on the notions that fractures are mainly caused by osteoporosis (pathophysiology), that patients at high risk can be identified (screening) and that the risk is amenable to bone-targeted pharmacotherapy (treatment). However, all these three notions can be disputed. PATHOPHYSIOLOGY Most fracture patients have fallen, but actually do not have osteoporosis. A high likelihood of falling, in turn, is attributable to an ageing-related decline in physical functioning and general frailty. SCREENING Currently available fracture risk prediction strategies including bone densitometry and multifactorial prediction tools are unable to identify a large proportion of patients who will sustain a fracture, whereas many of those with a high fracture risk score will not sustain a fracture. TREATMENT The evidence for the viability of bone-targeted pharmacotherapy in preventing hip fracture and other clinical fragility fractures is mainly limited to women aged 65-80 years with osteoporosis, whereas the proof of hip fracture-preventing efficacy in women over 80 years of age and in men at all ages is meagre or absent. Further, the antihip fracture efficacy shown in clinical trials is absent in real-life studies. Many drugs for the treatment of osteoporosis have also been associated with increased risks of serious adverse events. There are also considerable uncertainties related to the efficacy of drug therapy in preventing clinical vertebral fractures, whereas the efficacy for preventing other fractures (relative risk reductions of 20-25%) remains moderate, particularly in terms of the low absolute risk reduction in fractures with this treatment.
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Affiliation(s)
- T L N Järvinen
- Department of Orthopaedics and Traumatology, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland
| | - K Michaëlsson
- Section of Orthopaedics, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - P Aspenberg
- Clinical Sciences, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - H Sievänen
- The UKK Institute for Health Promotion Research, Tampere, Finland
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Zhu TY, Griffith JF, Qin L, Hung VWY, Fong TN, Au SK, Tang XL, Kun EW, Kwok AW, Leung PC, Li EK, Tam LS. Cortical thinning and progressive cortical porosity in female patients with systemic lupus erythematosus on long-term glucocorticoids: a 2-year case-control study. Osteoporos Int 2015; 26:1759-71. [PMID: 25736166 DOI: 10.1007/s00198-015-3077-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Accepted: 02/11/2015] [Indexed: 10/23/2022]
Abstract
UNLABELLED In this study, we characterized longitudinal changes of volumetric bone mineral density and cortical and trabecular microstructure at the distal radius using HR-pQCT in female systemic lupus erythematosus (SLE) patients on long-term glucocorticoids. Cortical thinning and increased cortical porosity are the major features of longitudinal microstructural deterioration in SLE patients. INTRODUCTION The study aims to characterize longitudinal changes of volumetric bone mineral density (vBMD) and bone microstructure at distal radius in female systemic lupus erythematosus (SLE) patients on long-term glucocorticoids. METHODS This 2-year case-control study consisted of 166 premenopausal subjects (75 SLE patients and 91 controls) and 79 postmenopausal subjects (44 SLE patients and 35 controls). We obtained areal BMD (aBMD) by dual-energy X-ray absorptiometry at multiple skeletal sites and indices of vBMD and microstructure at distal radius by high-resolution peripheral quantitative computed tomography (HR-pQCT) at baseline, 12 and 24 months. RESULTS In either premenopausal or postmenopausal subjects, changes in aBMD did not differ between patients and controls except that decrease in aBMD at total hip at 24 months in premenopausal patients was significantly higher. In premenopausal subjects, decrease in cortical area (-0.51 vs. -0.06 %, p = 0.039) and thickness (-0.63 vs. 0.02 %, p = 0.031) and increase in cortical porosity (21.7 vs. 7.16 %, p = 0.030) over study period were significantly larger in patients after adjustment of age and body mass index. Decreased in trabecular vBMD was significantly less (-0.63 vs. -2.32 %, p = 0.001) with trabecular microstructure better maintained in patients. In postmenopausal subjects, decrease in cortical vBMD (-2.66 vs. -1.56 %, p = 0.039) and increase in cortical porosity (41.6 vs. 16.3 %, p = 0.021) were significantly higher in patients, and there was no group-wise difference in change of trabecular microstructure. CONCLUSION Longitudinal microstructural deterioration in SLE is characterized by cortical thinning and increased cortical porosity. Cortical bone is an important source of bone loss in SLE patients on glucocorticoids.
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Affiliation(s)
- T Y Zhu
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
- Bone Quality and Health Center, Department of Orthopedics and Traumatology, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | - J F Griffith
- Department of Imaging and Interventional Radiology, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | - L Qin
- Bone Quality and Health Center, Department of Orthopedics and Traumatology, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | - V W Y Hung
- Bone Quality and Health Center, Department of Orthopedics and Traumatology, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | - T-N Fong
- Bone Quality and Health Center, Department of Orthopedics and Traumatology, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | - S-K Au
- The Jockey Club Centre for Osteoporosis Care and Control, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | - X-L Tang
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | - E W Kun
- Department of Medicine and Geriatrics, Tai Po Hospital, Tai Po, Hong Kong SAR, China
| | - A W Kwok
- The Jockey Club Centre for Osteoporosis Care and Control, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | - P-C Leung
- The Jockey Club Centre for Osteoporosis Care and Control, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | - E K Li
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | - L-S Tam
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China.
- Department of Medicine & Therapeutics, The Prince of Wales Hospital, 9/F Clinical Sciences Building, 30-32 Ngan Shing Street, Shatin, N.T, Hong Kong SAR, China.
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Abstract
STUDY DESIGN A posterolateral lumbar fusion model in osteoporotic rats. OBJECTIVE.: To assess the effect of alendronate on spine fusion in an osteoporotic animal model. SUMMARY OF BACKGROUND DATA The effect of alendronate on spine fusion is still controversial. Also, there are no studies using an osteoporotic animal model to assess the effect of alendronate on spine fusion. METHODS Forty-six female Sprague-Dawley rats underwent either sham-operation (sham) (N = 24) or bilateral ovariectomy (OVX)(N = 22). Eight weeks after the first surgery, animals underwent intertransverse spine fusion at L4-L5. Animals received saline or alendronate 70 μg/kg/wk by subcutaneous administration once a week for 8 weeks after spinal arthrodesis. All animals were divided into four groups: sham-control, sham-alendronate, OVX-control, and OVX-alendronate. After that the animals were killed and the fusion mass was assessed by radiographic, peripheral quantitative computed tomography (pQCT) scanning, and biomechanical and histologic analysis. RESULTS In the radiographic study and the pQCT scanning, the area of fusion masses of animals treated with alendronate was considerably larger and denser than that of the control animals in both sham and OVX groups. In the biomechanical study, the ultimate load of the fusion mass of alendronate-treated animals was higher than that of control animals in the osteoporotic groups. Histologic analysis of sagittal sections of fusion mass revealed greater new bone formation in alendronate-treated animals in osteoporotic models and significant inhibition of osteoclasts among the grafted area of alendronate-treated animals compared with the control models. CONCLUSION Alendronate was effective for radiologic, biomechanical, and histologic success of spine fusion in an osteoporotic animal model. Though much of the graft bone was not resorbed, alendronate increased biomechanical strength with ingrowth of new bone formation in osteoporotic animals. This study suggests the alendronate may improve spine fusion healing in the presence of osteoporosis.
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Sawada K, Morishige KI, Nishio Y, Hayakawa J, Mabuchi S, Isobe A, Ogata S, Sakata M, Ohmichi M, Kimura T. Peripheral quantitative computed tomography is useful to monitor response to alendronate therapy in postmenopausal women. J Bone Miner Metab 2009; 27:175-81. [PMID: 19152069 DOI: 10.1007/s00774-008-0025-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2007] [Accepted: 06/05/2008] [Indexed: 10/21/2022]
Abstract
A forearm fracture (Colles' fracture) is often the first sign of osteoporosis and may suggest underlying skeletal fragility. Therefore, establishment of a more accurate and reliable method for the measurement of bone mineral density (BMD) at the distal radius would be beneficial for patients who suffer from osteoporosis. The objective of this study was to evaluate the usefulness of peripheral quantitative computed tomography (pQCT) to monitor the response to alendronate therapy at the distal radius in early postmenopausal Japanese women. Thirty-two early postmenopausal women who were diagnosed with osteoporosis or osteopenia were randomized to either alendronate or control treatment. We analyzed the BMD of the distal radius by pQCT, lumbar spine by dual-energy X-ray absorptiometry (DXA) and the biochemical markers of bone turnover (deoxypyridinoline) at baseline, 3, 6 and 12 months. The control group showed a significant decrease from baseline in the trabecular BMD of the radius at 12 months (3.5 +/- 3.7%; p < 0.01), whereas the alendronate group showed a significant increase (4.3 +/- 8.1%). The changes in the trabecular BMD of the radius between the alendronate and control groups were statistically different at 6 and 12 months (p < 0.01). However, in the total BMD at the diaphysis of the radius, no significant differences were seen in the changes in bone densities between the alendronate and control groups after 1 year of treatment. pQCT detected significant differences in BMD of the radius in early postmenopausal women after 1 year of treatment with alendronate. Collectively, our preliminary clinical trial showed that pQCT might be useful to monitor response to alendronate therapy, especially at the radius, and it might explain why alendronate prevents Colles' fracture.
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Affiliation(s)
- Kenjiro Sawada
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka 565-0871, Japan
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Thorpe JA, Steel SA. The Alara Metriscan phalangeal densitometer: evaluation and triage thresholds. Br J Radiol 2008; 81:778-83. [DOI: 10.1259/bjr/69540165] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Papaioannou A, Kennedy CC, Freitag A, Ioannidis G, O'Neill J, Webber C, Pui M, Berthiaume Y, Rabin HR, Paterson N, Jeanneret A, Matouk E, Villeneuve J, Nixon M, Adachi JD. Alendronate once weekly for the prevention and treatment of bone loss in Canadian adult cystic fibrosis patients (CFOS trial). Chest 2008; 134:794-800. [PMID: 18641106 DOI: 10.1378/chest.08-0608] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Patients with cystic fibrosis (CF) are at risk for early bone loss, and demonstrate increased risks for vertebral fractures and kyphosis. A multicenter, randomized, controlled trial was conducted to assess the efficacy, tolerability, and safety of therapy with oral alendronate (FOSAMAX; Merck; Whitehouse Station, NJ) in adults with CF and low bone mass. METHODS Participants received placebo or alendronate, 70 mg once weekly, for 12 months. All participants received 800 IU of vitamin D and 1,000 mg of calcium daily. Adults with confirmed CF with a bone mineral density (BMD) T score of < - 1.0 were eligible for inclusion. Participants who had undergone organ transplantation or had other reported contraindications were excluded from the study. The primary outcome measure was the mean (+/- SD) percentage change in lumbar spine BMD after 12 months. Secondary measures included the percentage change in total hip BMD, the number of new vertebral fractures (grade 1 or 2), and changes in quality of life. RESULTS A total of 56 participants were enrolled in the study (mean age, 29.1 +/- 8.78 years; 61% male). The absolute percentage changes in lumbar spine and total hip BMDs at follow-up were significantly higher in the alendronate therapy group (5.20 +/- 3.67% and 2.14 +/- 3.32%, respectively) than those in the control group (- 0.08 +/- 3.93% and - 1.3 +/- 2.70%, respectively; p < 0.001). At follow-up, two participants (both in the control group) had a new vertebral fracture (not significant), and there were no differences in quality of life or the number of adverse events (including serious and GI-related events). CONCLUSION Alendronate therapy was well tolerated and produced a significantly greater increase in BMD over 12 months compared with placebo.
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Affiliation(s)
| | | | - Andreas Freitag
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - George Ioannidis
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - John O'Neill
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Colin Webber
- Department of Nuclear Medicine, Hamilton Health Sciences, Hamilton, ON, Canada
| | - Margaret Pui
- Department of Diagnostic Imaging, Scarborough Hospital, Scarborough, ON, Canada
| | - Yves Berthiaume
- Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | - Harvey R Rabin
- Adult Cystic Fibrosis Clinic, University of Calgary Medical Clinic of the Foothills Medical Center, Calgary, AB, Canada
| | - Nigel Paterson
- Schulich School of Medicine and Dentistry, University of Western Ontario, London Health Science Centre, London, ON, Canada
| | | | | | - Josee Villeneuve
- Le Centre Hospitalier Universitaire de Québec, Quebec City, QC, Canada
| | - Madeline Nixon
- Department of Medicine, McMaster University, Hamilton, ON, Canada
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